374603778-9-29-2025-08-AS-JROO-DRHSG4-20260221125116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603778
Report Date: 09/29/2025
Date Signed: 09/29/2025 03:06:24 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2022 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20220725103724

FACILITY NAME:	HERITAGE HILLS		FACILITY NUMBER:	374603778
ADMINISTRATOR:	LEMASTER, SUZY P		FACILITY TYPE:	740
ADDRESS:	2108 EL CAMINO REAL		TELEPHONE:	(760) 206-7930
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92054
CAPACITY:	78	CENSUS:	DATE:	09/29/2025
		UNANNOUNCED	TIME BEGAN:	11:36 AM
MET WITH:	Excutive Director Mike McCoy		TIME COMPLETED:	11:37 AM

ALLEGATION(S):

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Lack of supervision resulted in resident consuming hazardous chemical.

INVESTIGATION FINDINGS:

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On 9/29/2025, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Excutive Director Mike McCoy and explained the purpose of the call.

Regarding the allegation of Lack of supervision resulting in resident consuming hazardous chemical, Reporting party (RP) stated that a staff member mentioned a resident (R1) drank something from a Dr. Pepper bottle. When the staff member smelled it, it smelled like cleaning chemicals.

During the course of the investigation, 7 staff members were interviewed.

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20220725103724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HERITAGE HILLS	FACILITY NUMBER: 374603778
	VISIT DATE: 09/29/2025

NARRATIVE

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S1 mentioned that from the information S1 had heard or obtained, someone had left out a Dr. Pepper bottle that had been taken from another resident R2. The bottle was left at the nurse’s station. The bottle was capped and closed, but no one checked to see exactly what the contents were. Another staff S2, stated staff had been advised in the past to throw away any open food or drinks that are left out since the memory care residents may be inclined to take them. S2 stated R1 had taken drinks from staff in the past.

S3 stated that caregiving staff, in the past, have brought in cleaning agents from home such as Pine-Sol, Fabuloso, and Mr. Clean, diluted with water. The caregivers would bring in the cleaners to clean areas after residents “because of poop and pee.” S3 would bring in the cleaner Fabuloso but in its original bottle, and it always locked in her cleaning cart. S3 has never witnessed the staff bring the cleaning agents in bottles. S4 mentioned that the facility provides the cleaners to the housekeepers. There are four different types of cleaning agents that are dispersed by a machine which is in the rear area of the kitchen. The bottles are also provided by the facility. S4 also denies any care staff from the first floor bringing in their own cleaning agents from home.

S5 saw a Dr. Pepper plastic bottle full of yellowish liquid inside. The bottle was capped and closed. It was full and located at the lower counter of the nurse’s station, near the computer. S5 thought the bottle contained apple juice that was taken from the juice dispenser in the kitchen. S5 did not open to smell the contents because he didn’t want to smell what he thought was someone else’s drink. S5 observed R2 begin to reach and touch the bottle and S5 told R2 not to. R2 complied and left, and S5 left the bottle where it was located. When the incident happened, S5 went to where R1 was and was being tended to in the living room, and he/she saw the same Dr. Pepper bottle on R1s walker, half full. S5 instructed (a staff member) to check the bottle which was capped. As the staff member took the bottle, he/she accidentally dropped the bottle, and the liquid began to “bubble.” The caregiver opened the bottle, and it smelled like soap. It was never determined who had initially put the bottle at the nurse’s station. All staff denied the bottle belonged to them. S5 denies any knowledge of staff bringing in their own cleaning agents or liquids from outside the facility.

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SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20220725103724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HERITAGE HILLS	FACILITY NUMBER: 374603778
	VISIT DATE: 09/29/2025

NARRATIVE

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***This is an amended report ***
S6 was assisting monitoring residents in the TV living room, where residents were watching a movie. S6 was seated in the back of the room in the last row of seating. R1 was seated to the front of the room. A caregiver (doesn’t remember who) began to come into the room to assist and escort residents back to their rooms. The caregiver then approached R1 and stated R1 did not look good and was “gagging.” S6 observed the Dr. Pepper bottle on R1s walker. S6 picked it up to examine it and noticed a pinkish-orange transparent liquid inside, as if it was flavored water. S6 uncapped the bottle and it smelled like Pine-Sol or some other type of cleaning solution. S6 is not aware, or has never witnessed, any staff member bringing their own cleaning agents from home. Since the incident, staff were directed not to keep any personal items on the floor and to keep the nurse’s station clear. S7 explained that he/she went into the TV living room to begin assisting R1 back to the room. R1 appeared as if R1 was “drunk” and had clear saliva coming from his/her mouth. S7 lightly tapped and moved R1 to wake R1 up, and R1 began vomiting clear liquid. S6 responded, and it noticed there was a half full Dr. Pepper bottle at R1s walker. S7 denies knowing of any staff bringing their own cleaning agents to the facility in bottles.

Based on records review, R1 needs to have safety checks every four hours, but on the physician’s report supervision is noted as 24 hours supervision/care management.

Since there staff had been advised in the past to throw away any open food or drinks that are left out since the memory care residents may be inclined to take them but still left the bottle by the nurse’s station, the facility wasn’t able to supervise R1 for R1 not to take this bottle since there is an unknown liquid contained in it.

At the time of the complaint inspection on 8/3/2022, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49.

Based on observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D.

Report is reviewed and a copy of the report and Appeal Rights is provided.

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SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20220725103724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HERITAGE HILLS	FACILITY NUMBER: 374603778
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/01/2025 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents...	1 2 3 4 5 6 7	Licensee to provide an in-service training for staff regarding supervision of residents. Licensee to submit by POC Deadline.
	8 9 10 11 12 13 14	This was not met as evidenced by: Based on interviews and records review, R1 was able to ingest a chemical that was left unlocked/unsupervised by facility staff which poses an immediate Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025

LIC9099 (FAS) - (06/04)

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